Job Description

As a Claims Processor you'll be responsible for reviewing and processing insurance claims to determine the appropriate action to be taken. This role involves gathering information, evaluating claims for validity, and ensuring that all necessary documentation is complete.

This is a hybrid in office position located in the Tampa Bay, Fl area. You will be required to be in office twice a week.

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• Medical Claims Processing - Accurately review, verify, and process insurance claims following the company policies/SOPs.                                               

• Documentation Review - Analyze claim documents, medical records, benefit summary to determine claim eligibility and process the claim as per the benefit.                         

• Customer and Internal Business Partner Interaction - Communicate with member, healthcare providers, and internal business partners to resolve the claim or gather required additional information.     

• Data Entry - Enter claim details and maintain accurate records within the claims management system.                                                                              

• Problem resolution - Investigate discrepancies and resolve disputes related claim processing          

• Rework Adjustment Experience - Should be able to perform the rework adjustment basis the provider request and internal rework/adjustment requirement.

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• ICD-9 &10 Coding
• Customer Service                                                                                  
• Computer skills with knowledge of Outlook. Word & Excel 
• Expert knowledge with a minimum experience of 1-2 years in Healthcare and claims processing.  
• Experience in Govt. Ops with a experience of Medicare and Retirement / Medicaid claims processing.                                                                                      
• Able to explain the terms, Copay, Coinsurance, Deductible and out of pocket.                
• Able to describe Medicaid and Medicare eligibility in detail.                                                         
• Experience in M&R / Medicaid Rework/Adjustment claims processing preferred.                                      
• Excellent Communication Skills (Verbal & Written)                 
• CMS 1500 & UB Form Experience is a PLUS! 

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• Build capability to ensure operational excellence and maintain superior customer service levels of the existing account/client
  • Undertake product trainings to stay current with product features, changes and updates
  • Enroll in product specific and any other trainings per client requirements/recommendations
  • Partner with team leaders to brainstorm and identify training themes and learning issues to better serve the client
  • Update job knowledge by participating in self learning opportunities and maintaining personal networks

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